COLLABORATIVE MENTAL HEALTH CARE – WHERE COULD

WE GO?

Nick Kates, MB.BS, FRCP (C) MCFP (hon)

Chair, Dept. of Psychiatry

McMaster University

Quality Improvement Advisor,

Hamilton Family Health Team

Thank you

• Peter Selby • Arun Ravindran

• Marina Bourlak • Rosa Dragonetti • Myra Fahim • Julia Lecce

• Terry Isomura • Sari Ackerman

Plan

• Forces driving / enabling collaboration

• A new role for primary care

• Opportunities for improving the quality of

what we do

• Things that can make this happen

Forces Driving Collaboration –1997

The World in 1997

Forces driving better collaboration in 1997

• Problems in the relationship

• Need to improve access / wait times

• Desire to support primary care / increase

skills and comfort

• Need to improve communication between

the two sectors

And in 2014

Forces driving better collaboration

• Reducing preventable emergency visits

• Containing costs/ increasing efficiencies

– Reducing preventable ED visits

– Improving transitions

• Addressing co-morbid conditions / complexity (Health links)

• Improving the quality of care

• Reducing disparities

• Increasing evidence that it works

• Acceptance by funders and planners

Other factors

Other factors

Other factors

And ……….

The economic impact of Integration Impact for Psychiatry

AMA resolution to implement integration of Physical and Behavioural Health

Focus on Integrating Physical & Behavioural health

Co

What works – key principles • Policy & plans

• Advocacy

• Training

• Doable and limited interventions

• Mental health service support

• Co-ordinators or care

• Access to medication

• Resources – human and funding

• Collaboration with other sectors

• Process not an event

Crossing Boundaries (Kings College Mental Health Foundation)

• Multidisciplinary Teams

• Information-Sharing

• Shared care protocols

• Joint funding

• Liaisons

• Navigators

• Reducing stigma

• Research

• Co-location

9 key components for successful collaboration

What works – key elements 011 Position paper

• Care Co-ordinator

• Access to Psychiatric consultant

• Enhanced consumer education

• Introduction of evidence-based approaches

• Screening of people with chronic medical

conditions for depression or anxiety

• Skill enhancement for primary care providers

• Access to brief psychological therapies

Importance of personal contacts

Friendship Balance Respect Equality

Qualities of a good consultant • Affable • Available • Able

What still prevents us from collaborating • Physician remuneration models

• Funding models

• Attitudes

• Cultures of care

• Power and control

• Comfort / convenience

• Training

• Not taking full advantage

of team

• How are our systems are designed

Thought for the Day

Systems are

perfectly

designed to get

the results they

achieve. Paul Batalden

Failures to collaborate are often system failures

Improving collaboration

Better collaboration and delivering better quality care require changes in

the way our systems of care are conceptualised and organized, both

within and between systems.

Where could we be heading and what can we achieve –

the vision thing

Beware of Great Predictions

In 1943 Thomas Watson, Chairman of IBM, reportedly predicted:

“I think there is a world market for about five computers.”

We need a new vision of the role of primary care in an integrated

mental health system

The potential role of Primary Care Looks after a population

Enduring relationships with the individual and their family

Screening and early detection

Initiation of treatment

Monitoring and follow-up

Co-ordination and continuity of care

Referral and system navigation

Family interventions

Point of entry into an integrated MH&A system

Could provide more (and effective) MH&A care

Mental Health and Addiction Services

• Provide rapid access to consultation and advice

• Respond quickly to help with urgent problems

• Priorize people who cannot be managed in PC

(complexity /resources) and provide ongoing care

• Stabilize problems, and return to primary care providers for ongoing management and monitoring,

• Continue to be available to / support the PC Team (shared care)

• Provide information on and link with community resources

Early

Detection Monit-

oring

System

Links Health

prom-

otion

Initiate

Treat-

ment

Care Co-

ordination

Family

support

Communication

Co-Location

Integration Co-ordination

Consultation

Primary Care

Person

Family

Consultation

Urgent Care

Ongoing Care

Linkage Support

Mental Health Stabilise

Build capacity

How do we take full advantage of the role that primary care

can play?

- Effective

- Safe

- Timely

- Consumer and family- centered

- Equitable

- Efficient

- Integrated

- Focused on population health

Quality health care

A high-performing health system that is:

More effective care - Increasing the capacity and skills of primary care

• Translate MH concepts and tools

• Teach / model relevant skills – Motivational Interviewing – PHQ-2

• In-Office education Program / on-line resources

(BCs Adult Mental Health Module) • Child / geriatrics / addictions

• Increasing comfort Primary Mental

Health Care is not just Mental Health Care in a Primary Care Setting

Primary Mental Health Care is not just Mental Health Care in a Primary Care Setting

Safer care

• Every person has a plan and is given a copy of their plan, which is updated at every visit • Medication reconciliation at every visit • Transitions

More efficient care

• Better integration of physical and mental health care – Co-morbidities

– Complex conditions

– Opportunities for earlier detection

– Addictions

– Medical care of people with mental health problems (reverse shared care)

DETECT PROBLEMS EARLIER (AND INTERVENE!)

• Enhanced 18 month visit

– Not an end

– Follow-up

– Identify those at greatest risk (Red, yellow, green)

– Make sure those with needs reach services they require

In my

beginning is my end

TS Elliot

Population focus

• Proactive care

– Monitoring

– Relapse prevention

Better integrated care

Better integrated care

Community partnerships

• Need to address social and environmental determinants

• Need to work with community partners

• Build community resilience

Need to improve care for individuals

• Comprehensive plans

• Address non-medical issues

• System navigation

• Working in agencies

Integrate Community Programs within Primary Care Settings

“To alter our delivery system to reduce costs and put an emphasis on prevention”

The Second Stage of Medicare

CONSUMER CENTRED CARE

Re-designing services based on a person or family’s experience

Family engagement

Promote recovery / support self management

Reducing inequities

More equitable care

• Address disparities in access as well as outcomes • Identify and eliminate stigma in our own settings

Enablers to help us get there

IHI’s Triple Aim

• Better health for populations (better health)

• Better experience of seeking / receiving (providing) care (better care)

• Sustainable and cost efficient (better value)

• And all at the same time

Making the case for Collaborative Mental Health Care

• Evidence

• Advocacy

• Networks (tipping point)

• Spread of ideas that work

• Cost-benefit analyses

Preparation of Future Practitioners

• Training

• Competencies

• Preparation